Are doctors ‘gaming’ the incentive programs? CMS wants to know

Medicare has hired a contractor to ferret out and recover improper bonuses paid to physicians for quality reporting and electronic prescribing efforts.

Under a $9.9 million contract, Arch Systems of Baltimore will validate the accuracy of data submitted to the Electronic Prescribing Incentive Program (eRx) and Physician Quality Reporting System (PQRS), specifically targeting quality data submitted through registries and the group practice reporting option. Data submitted via the widely used claims-based reporting option could be included in subsequent reviews.

Dr. Bruce Bagley

"Since the inception of the PQRS and eRx incentive programs, there have been reports uncovering data-integrity issues and misunderstandings regarding data submissions, and suspicious attempts of ‘gaming’ the system to earn the PQRS and/or eRx incentive payment," according to documents from the Centers for Medicare & Medicaid Services. "Despite extensive education and outreach efforts, mandatory support calls, and special training sessions, these data issues persist."

The data have been validated once already, CMS spokesperson Don McLeod said in an interview. During these checks, the agency discovered issues in which information submitted by eligible providers did not match data in the agency’s records.

"The intent is to ensure that the data that is used by aligning programs [such as the Physician Value Based Payment Modifier or the Physician Compare website] is accurate and valid," he said.

Most registries are run by third parties, but all are certified by CMS. The agency is seeking to verify that the data sent by registries on behalf of providers are accurate.

Physicians have been encouraged to incorporate registries into their practices because of the potential to improve quality at the point of care, according to Dr. Bruce Bagley, interim president and CEO of TransforMED, a subsidiary of the American Academy of Family Physicians. Some registries can produce a list of patients with a specific condition, give a snapshot of applicable quality measures, and show gaps in care.

The scope of the review raises a concern of creating another program similar to the CMS recovery audit contractors program, said Dr. Richard Duszak Jr., a Memphis, Tenn., radiologist and chief medical officer of the Harvey L. Neiman Health Policy Institute at the American College of Radiology. The RAC program poses a significant administrative burden for practices as they seek to recoup overpayments to physicians and hospitals. RAC audits have forced providers to return $5.4 billion since October 2009.

In their inimitable way, the Centers for Medicare and Medicaid Services has announced that once again they are concerned there is doctor fraud occurring in two of their recent incentive programs. They have set up another watchdog group by contracting with a company to validate the accuracy of the data from the complex and burdensome paperwork required by practices to incorporate patient registries in the PQRS and eRx programs, which are hoped to improve the quality of care. The average incentive earned by physicians in 2011 was slightly over $1,000, which likely doesn't even cover the increased administrative costs for their practices. Ultimately the PQRS data will be used to administer their upcoming value-based modifier program. If indeed CMS finds little actual fraud, it is highly unlikely they will publicly announce that doctors are participating in an honest and ethical manner in another of their onerous programs.